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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Serie: SCSW - Skills for contemporary Social Work
- Sprache: Englisch
Assessing and managing risk is a daily challenge for social workers. Working with risk can be anxiety provoking and demanding, requiring great skill and high levels of confidence. In these complex situations, social workers have to work hard to get the balance right.
This innovative book focuses on the development and use of skills for work with risk. Using a range of case studies, examples and reflective exercises, the authors examine the key skills required to work effectively with risk. Various chapters focus on assessment skills, gathering and evaluation of information, decision-making challenges, and ethical issues. Recognising the difficulties presented in the context of busy statutory work, there is a strong focus on practical skills and tips for improving risk management plans. The book also pays careful attention to the emotional impact of working with risk, with a final chapter on the management of self in the challenging and sometimes distressing world of social work.
Written in a reader-friendly, accessible style, the book will be essential reading for students and staff across a range of social work settings, including community care, adult services, child protection and mental health.
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Seitenzahl: 323
Veröffentlichungsjahr: 2013
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Table of Contents
Cover
SKILLS FOR CONTEMPORARY SOCIAL WORK SERIES
Title page
Copyright page
Figures and Activity Boxes
Figures
Activity Boxes
Acknowledgements
1: Understanding Risk
What is Risk?
Understanding Risk in Social Work
Structure of the Book
2: Skills for Risk Assessment
The Focus of Risk Assessment
Defensible Practice
Approaches to Risk Assessment
Risk Factors and Estimating Future Risk
Understanding Cause and Effect
A Range of Essential Skills and Abilities in Risk Assessment
Organizational Skills
Communication with Other Professionals
Communicating with Service Users
Conclusion
3: The Art of Decision Making
Skills Required to Exercise Sound Judgement and Make Good Decisions About Risk
Understanding the Emotions, Values, Attitudes and Biases that Affect Decision Making in Negative Ways
Alternative Frameworks for Decision Making: Rehearsing Risk Scenarios
Conclusion
4: Risk Planning and Management
Thresholds and Categorization
Key Stages in Planning and Delivering Risk Management
The Goal of Risk Management
What Needs to Change?
How Will Change be Brought About?
Timescales and Sequencing
Contingency Planning
Recording, Monitoring and Review
Skills in Working with Others
Conclusion
5: Risk and Ethics
Role, Responsibilities and Ethical Beliefs
Service-User Rights and Choices, and the Management of Risk
The Ethics of ‘Making Do’
Role Boundaries: Compromise and Collusion
Summary and Conclusion
6: Review and Evaluation of Risk
Learning from Inquiries and Serious Case Reviews
Effective Risk Systems
Monitoring, Audit and Quality Assurance
System Oversight
Learning and Improving
Summary and Conclusion
7: Managing Self in the Organizational Context
Self-Management Skills
Motivation to Engage with the Task
Knowledge, Skills and Reflection on Practice
Coping with Stress: The Importance of Resilience
Self-Management Skills and Risk
Taking Steps to Support Organizational Survival
Conclusion
Conclusion
Assessing Potential Risks
Responding to Risk
Working Positively with the Challenges of Risk: A Shared Commitment
References
Index
SKILLS FOR CONTEMPORARY SOCIAL WORK SERIES
Copyright © Hazel Kemshall, Bernadette Wilkinson and Kerry Baker 2013
The right of Hazel Kemshall, Bernadette Wilkinson and Kerry Baker to be identified as Authors of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2013 by Polity Press
Polity Press
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Cambridge CB2 1UR, UK
Polity Press
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Malden, MA 02148, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-0-7456-5197-2
ISBN-13: 978-0-7456-5198-9(pb)
ISBN-13: 978-0-7456-7208-3(epub)
ISBN-13: 978-0-7456-7209-0(mobi)
A catalogue record for this book is available from the British Library.
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been inadvertently overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website: www.politybooks.com
Figures and Activity Boxes
Figures
1.1The cycle of working with risk2.1Interacting risk factors4.1Strength of interactions between risk factors4.2Model of combined risk strategies and gaps6.1Serious incident review cycles6.2Framework of knowledge and organizational commitment7.1The iceberg model7.2Accountability, reflection and learning, and best practiceActivity Boxes
2.1Holding the Balance between Risk Avoidance and Positive Risk Taking 2.2Being Clear About the Purpose of Risk Assessment2.3Benefits and Harms2.4Supporting Defensible Decision Making2.5Evaluating an Assessment Procedure2.6Risk Factors and Causation2.7Self-Reflection: Strengths and Areas for Development2.8Planning an Assessment2.9Communication2.10Observing and Analysing Practice2.11Reflecting on an Interview2.12The Quality of Information2.13Returning to Your Attributes and Skills3.1Considering Ambiguous Factors3.2Testing Information Sources3.3Case Study Exercise3.4Case Study Exercise and Reflection3.5Testing Inductive Hypotheses on Risk3.6Reflective Exercise: Negative Emotions and Risk Assessment3.7Reflective Exercise: Balancing Risk Decisions3.8Dealing with Risk Dilemmas3.9Exercise on Bias4.1Thresholds and Categorization4.2Balancing Risk Reduction against Potential Negative Outcomes4.3Balances in Risk-Management Plans4.4Different Kinds of Risk Factors4.5Thinking about the Strengths and Directions of Influence4.6Layers of Risk Strategies4.7Writing Approach Goals4.8‘Means–End Thinking’4.9Footsteps to Change4.10Scenario Planning4.11Remembering the Potential for Positive Change4.12Reading Case Records4.13Agency and Practitioner Perspectives in Risk Meetings5.1Case Study5.2My Own Ethical Beliefs5.3The Challenges of Rationing5.4Threats to Personal and Professional Integrity5.5Can I Lie to You?5.6Challenge and Reporting5.7Risk Avoidance and Risk Aversion6.1Reflective Exercise on Opportunities for Learning6.2Responding to Recommendations6.3Organizational Responses to Serious Incidents6.4Learning from Recurring Problems6.5Knowledge of your Local Risk Policy6.6Testing Fitness for Purpose6.7Identifying What You Need to Know6.8Case Studies6.9Asking the Unasked Questions6.10Improving System Oversight7.1Your Own Characteristics7.2Using Critical Reflection7.3Your Personal Efficacy Beliefs and Their Effects7.4Managing Stress7.5Using Self-Management Skills 17.6Using Self-Management Skills 27.7What is Happening ‘Under the Surface’7.8Informal Discussions7.9Making the Most of Supervision7.10Making the Most of Learning Opportunities7.11Strategies for Self-Management in the Organization8.1Achieving ‘Balanced’ Practice8.2ReflectionAcknowledgements
We would like to thank all the people who have helped with this book, including those who have participated in our training over the years, students and staff of social work courses who have tried some of this material, and staff at the University of the West of Scotland who provided a number of activities. Our thanks also go to Katie Heaton, team leader at Warwick Children and Families Services, for comment and ideas. Thanks also to Kath Hammersley at De Montfort University for formatting and improving the manuscript.
We would like to extend heartfelt thanks to our families and friends who have provided encouragement and support and who have helped us to complete this book. Thanks also to the staff at Polity, including a very patient Jonathan Skerrett who was very kind about deadlines.
1
Understanding Risk
Risk assessment and management are core issues in social work across a range of settings and contexts. Responding to the risks posed by others, reducing risks to vulnerable persons and managing risks to themselves are all in a day's work for busy practitioners. Managers and practitioners are routinely confronted with risk decisions, and such decisions are often central to the allocation of resources or the choice of interventions (Kemshall 2002a). Risk is a complex practice issue, and there are different views on the nature of risk, and how to assess and manage it effectively. This chapter will explore the nature of risk, the historical roots of risk as a concept and how it is best understood for those working in social work.
What is Risk?
Risk has been called the ‘world's largest industry’ (Adams 1995: 31). We are faced with a bewildering array of risks in our everyday lives, ranging from health risks due to eating the ‘wrong foods’ to flood risks caused by climatic change. We are constantly told about such risks through the media, and constantly urged to be more aware and to ‘manage’ risk. At the turn of the century, one journalist expressed our preoccupation with risk in the headline: ‘Warning: You're Risking Death by Being Alive’ (Thomson 2000: 21). Thomson painted the twenty-first century as a risky place, noting risks to newborn babies arising from their mothers’ kisses, to vaccines, to cot death, food risks and paedophile abductions on the way to school. As she put it, being a mother is a risky business, and ‘every day there is another reason to worry.’ Some risks we choose to accept (those associated with travel are readily accepted as the ‘price’ we pay for moving around); some risks we actively seek (like gambling or bungee jumping for the thrill); some we seek to avoid (like becoming the victim of crime). Other risks are beyond our personal control, for example those associated with nuclear power plant discharge, such as the Fukushima disaster in Japan, or acid rain. These are risks emanating from far away and often caused by others we do not know or control, or by the failure of regulatory systems set up to protect us.
The word ‘risk’ can also have different meanings. To some ‘risk’ means thrill, or the chance of gaining a reward for minimum effort (gambling), and risk-taking is an acknowledged and usually valued feature of entrepreneurship and venture capital (Higgs 1931), at least until the excesses of the global financial crisis of 2008. Increasingly, however, ‘risk’ has been linked to danger, peril and hazard (Oxford English Dictionary 2012) and used almost entirely with negative connotations. One consequence of this has been a developing culture of risk aversion (Power 2004), reflected in a precautionary or ‘better safe than sorry’ approach to risk. This in turn can lead to defensive practice, and organizational cultures that are focused on risk avoidance and blame.
The framing of risk as danger has a long history, and the English term ‘risk’ came into common usage in the seventeenth century with the development of marine insurance. The rise of the slave trade and the extensive shipment of cotton led to formal calculations of safety levels on shipping routes, in effect calculating whether a ship was likely to return to port safely or not and insuring appropriately against any loss (Kemshall 2003). Lloyd's of London famously started this business, and utilized statistics, especially on death rates and shipping losses, to produce actuarial tables of risk (Hacking 1987). The insurance industry still operates in this way today. In 1762, Equitable Life set up the first life insurance and again drew on actuarial tables of death rates across the population as a whole to ensure calculations of life expectancy; life insurance policies were calculated and costed accordingly. The Napoleonic Wars saw further interest in life insurance, particularly for ‘soldiers of fortune’ selling their services. Many came from Scotland, and life assurance was sought for the widows and orphans that might be left behind. The company we now know as Scottish Widows has its roots in this era. By the nineteenth century, insurance was a common industry, and the notion of risk as a probability calculation based on tables of data was firmly embedded (Hacking 1987, 1990). Probability and therefore prediction of risk were linked; risk could be known and assessed if only the right tools were used (Daston 1987).
The late nineteenth and early twentieth century saw the extension of insurance and probability calculations of risk into social life. For example, mutual societies enabled the working man to insure against accident or illness, and such societies were common in coal mining areas, extending later into many areas of industrial life. The Co-operative Society was one of the largest mutual societies and has its roots in the heavy industries of the north of England. The notion of pooling resources to deal with individual risks of misfortune was strongly embedded in the British welfare state for much of the twentieth century, and across other anglophone nations (Kemshall 2003). Personal risks and misfortune were not merely a matter for the individual, but were seen as part of the collective state response, for example through welfare benefits for those too ill to work.
By the late twentieth and early twenty-first centuries, actuarial or probability calculations of risk had become common across many aspects of social life, and formalized risk assessment tools began to play a key part in assessments of welfare entitlement, in social work, social care and crime management policies (Kemshall 2002b). Interestingly, as techniques for risk assessment improved, the idea of a collective response to individual risks began to wane. The burgeoning costs of welfare across all the anglophone countries resulted in aggressive social policies to reduce the size and responsibilities of the state, a situation given considerable impetus by the global financial crisis of 2008. Risk and responsibility became entwined, with much social policy placing responsibility for assessing and managing risks onto the individual. Personal misfortune became exactly that, and citizens are increasingly expected to foresee and manage their own risks (e.g. saving for old age, insuring against unemployment). In social work, risk has come to predominate as a way of categorizing users, cases and responses, and social work's focus is often on those citizens who are deemed to take risks irresponsibly, or who pose risks to others and therefore require managing (Kemshall 2010a).
Understanding Risk in Social Work
We are all faced with numerous risk decisions in our personal lives, but professional decisions about risk are different. As Carson and Bain put it, ‘professional risk-taking is undertaken for the benefit of others from a duty to assist them’ (2008: 31). This is the underlying imperative for risk decisions in social work.
Risks in social work can be separated into two broad categories:
those risks which people pose to others; andthose risks to which people are exposed, in other words, people who are vulnerable to risk. (Kemshall 2002a: 124)One of the most obvious social work areas in which people pose a risk to others is in child protection. Parents and other adults may pose a range of risks to children, ranging from physical risks, sexual abuse, neglect and risks arising from particular adult lifestyles, such as alcohol or drug use. In these circumstances, workers will not only focus on the needs of the child but will be concerned to accurately assess the type of risks posed; how likely they are to occur, when and how; and what interventions can be put into place to reduce the risk. In such situations, the rights of the poser of risk can be limited in the interests of protecting others or of preventing further risks.
Assessing vulnerability to risk is equally relevant to a number of service-user groups and to a number of settings, for example, care of older persons, work with vulnerable adults, support for young people leaving care. What is critical to assessments of risk in this area is: a clear focus on the risks the person is exposed to; how they might impact on the person and with what consequences; whether such risks are acceptable or not; what risk reduction strategies can be used and how these might impact on the quality of life and autonomy of the person and with what benefit(s); and how risk management can be balanced with the promotion of autonomy, quality of life and individual rights (Kemshall 2002a: 125).
However, in daily practice, such neat distinctions don't always apply. Some service users will fall into both the categories of posing risk and being at risk. For example, young people leaving care may commit offences and present risk to others, but will also be vulnerable to abuse from older adults, and at risk because of poor accommodation, lack of employment and lack of support and care. A number of high-profile cases have also highlighted the vulnerability of mentally disordered persons who have committed serious offences. The inquiry by Blom-Cooper, Hally and Murphy (1995) identified how failures in community care contributed to the escalation of risk in the case of Andrew Robinson and his subsequent killing of Georgina Robinson. The inquiry noted the failure of treatment, and the failure to respond to Robinson's deteriorating mental health and the concerns of his family and friends. Andrew Robinson had a history of mental illness since 1978 and had been in Broadmoor Special Hospital following a conviction for possession of a firearm with intent to endanger life. Robinson presents as both vulnerable and as a potential poser of risk to others. The case also illustrates how the risks that a person is exposed to can exacerbate the risks they pose to others. In such cases, it is important that the practitioner assess both types of risk – if the focus is only on vulnerability, the risks to others are overlooked; if the focus is only on posing a risk to others, then key issues in the person's life will remain unaddressed and these may heighten risk to others over time. Once the practitioner has assessed risk and vulnerability, the important next step is to consider how they interact, what will exacerbate risk and what might mitigate those risks.
Addressing these difficult and challenging risk issues is the focus of this book. The emphasis is not on risk assessment as a ‘tool’ or a process, but on risk assessment as a decision and, in many cases, risk assessment as a series of decisions. Complex, significant, life-changing decisions require skill and competence, and acquiring skill and building competence are key themes in this book. While bureaucratic and administrative procedures attempt to ‘tame chance’ (Hacking 1987), and a plethora of structured risk-assessment tools have been developed, risks are not always assessable through formal probabilistic assessment tools, due to lack of knowledge, and are subject to a number of ‘it depends’. Social workers have to operate in a ‘climate of uncertainty’, in which a proportion of decisions will have poor outcomes. Practitioners have to make decisions in situations of stress and under the spectre of potential blame, and in contexts where service-user views of risk and those of workers may be at odds. As Baker and Wilkinson put it: ‘Practitioners and managers are faced with the challenge of making demanding decisions about risk with the added pressures of working in a climate of limited resources and intense media and political scrutiny’ (2011: 13). This book aims to help both those training to become social workers, and those already in the profession to make those demanding decisions.
Structure of the Book
It is no accident that the word ‘skills’ features in the subtitle of this book. Acquiring skills through reading is of course difficult, and social workers can only improve their practice through practising and reflecting. Through the use of case studies and reflective exercises, this book fosters such an approach. The book attempts to follow the ideal practice journey of risk assessment, formulating risk plans and comparing options, implementing risk-management plans, reassessing and reflecting on impact and outcomes, and revising plans where appropriate. This cycle requires key tasks to be performed, including preparation for the assessment task, information gathering, analysis of what is found, risk-management planning, delivery as intended, and review, all of which should be supported by thorough recording. This is expressed in Figure 1.1.
Figure 1.1 The cycle of working with risk
The book focuses on this critical process, with chapter 2 introducing the assessment procedures, with an emphasis on purposeful information gathering and in-depth analysis. Chapter 3 looks at the exercise of ‘good judgement’ and argues that informed, balanced and critical reasoning are essential to sound decision making. The pitfalls of risk-decision making, for example those created by bias and discrimination, are explored, and challenging risk decisions are also recognized as ones which can lead to defensive practice. Chapter 4 examines risk planning and management and argues that effective plans must flow from a balanced, evidence-based risk assessment. Importantly, the chapter focuses attention on the identification of desirable risk reduction outcomes, and how planning must demonstrate how these are likely to be achieved. Plans also have to be delivered and reviewed, but rightly the chapter encourages readers to consider the requirement for flexibility in the light of change and the dynamic nature of risk. Contingency planning and mechanisms for monitoring implementation are required, and plans require review in order to establish that they are working and delivering desirable outcomes.
Risk assessment and management also present key dilemmas and challenges for social workers. These are areas of work particularly prone to ethical dilemmas and can present tensions between ‘social control, social care, social justice and social change’ (Barry 2009: 111). Chapter 5 examines a range of such tensions and likely challenges for social workers and presents a number of exercises to encourage the reader to rehearse and reflect on how such challenges can be faced and resolved. The discussion is informed by contemporary ethical codes in social work, but the limits of such codes in resolving real-life ethical dilemmas are acknowledged.
Review and evaluation of risk management is critical, but this can involve more than the review of individual plans. Chapter 6 locates review and evaluation within the wider context of risk policies, procedures and systems, and looks at the role of managers as well as practitioners in delivering effective and balanced risk management. Learning from both good practice and risk failures is seen as critical for improving performance, and the chapter also examines how quality assurance can be improved.
Decisions about risk also take place under conditions of uncertainty. We can never truly know all there is to know, and decisions do not take place under ideal conditions (for example, there are almost always time pressures and resource constraints). These conditions can often make us feel anxious and stressed. It is therefore important that we can manage these impacts on ourselves, and chapter 7 examines in some detail how best to ‘manage self’ within the demanding organizational context of social work. Reflective practice is seen as one key technique for helping social workers deal with a demanding and stressful job, where blame is often only one decision away. To assist readers with critical reflection, the reader is invited to engage with a range of activities, case studies and reflective exercises throughout the book. These can be used on social work training courses, in work settings to review practice, and with social work teams for staff development. Where relevant, feedback is provided, and activities are boxed and numbered for ease of access.
Finally, the conclusion recognizes that risk decisions are often life-changing ones and seeks to reiterate a number of key themes and good practice messages from the book. Working positively with risk, and in an informed and balanced manner, is seen as critical. This book does not have all the answers, but aims to help social work practitioners to make positive, thoughtful, robust and ethical decisions about risk.
2
Skills for Risk Assessment
Risk assessment is not an end in itself; however, it must be purposeful. Figure 1.1 made clear that information gathering and analysis at the outset of any case should guide service delivery. As planned-for services are delivered, the impact of any actions taken (and of actions not pursued) should be reviewed, contributing to a developing picture and often necessitating new information gathering and analysis.
This purposeful risk-assessment practice will be built on a range of interrelated and mutually dependent skills and knowledge, including the practical use, in context, of relevant legislation and policy. Communication skills are important for example, but effective communication may also require skills in managing conflict and challenge (Keys 2009b), so that again the practical application of skills in context is central.
So how effectively have relevant risk-assessment skills and knowledge been applied in social work and if not always effectively, why not? There have been well-documented and publicized concerns about the effectiveness of the risk-assessment and management process in social work, particularly in relation to child protection (Laming 2003, 2009) and for those working with the mentally ill (NHS London 2006). While the hope is always that inquiries and investigations into practice will improve outcomes, they have not always had the intended effect. Responses by commentators and policy makers can be polarized; for example, Maden (2011) suggests that the debate about violence and mental health has been characterized by extremes, with focus on assaults by the mentally ill and concerns about their human rights being unhelpfully seen as mutually exclusive. Practitioners will find it harder to exercise skills with confidence if they are struggling to locate their work in a very politicized and polarized context. Responses to inquiries can be bureaucratic and procedural in nature (Reder and Duncan 2004a) and are also influenced by considerations of resource management with sometimes conflicting demands on the available and limited resources (Davies 2008). This has contributed to an organizational focus on procedures, with less attention paid to the skills and understandings that are essential, whatever the procedural basis of practice (Brandon, Dodsworth and Rumball 2005; Keys 2009a, b; Munro 2011). ‘The focus on work with risk becomes data storage and communicating risk, with less attention to service-user engagement or to risk management itself’ (Kemshall 2010a: 1255).
Given the climate of scrutiny of risk decisions in modern society, it is perhaps unsurprising that discussions tend to focus on risk avoidance: the attempt to prevent harm occurring by identifying and tackling those risk factors which increase the likelihood of a harmful event. It is important at the outset, however, to emphasize that effective work with people doesn't just involve the avoidance of risk but also requires the taking of positive risks to support personal growth and development (McDonald 2010a; Titterton 2011). Manthorpe and Moriarty (2010: 8) talk about risk enablement: ‘the process of measuring risk involves balancing the positive benefits from taking risks against the negative effects of attempting to avoid risk altogether.’ Risk assessment needs to look for and find opportunities to build on the resilience and strengths in individuals and situations. The skills utilized in risk assessment therefore include skills in holding the balance between planned and purposeful risk taking and risk avoidance.
To think this balance through, consider an example from everyday life. Parents have to decide, bearing in mind the age and characteristics of their child and the circumstances in which the family lives, what degree of freedom of movement is appropriate.
What lessons can you learn from this for risk assessment in social work?
The Focus of Risk Assessment
‘Risk assessment’ is now a frequently heard phrase but it is important to think carefully about the language that is being used and what terms like this actually mean in practice. Risk assessment includes a consideration of two key elements (Carson and Bain 2008):
the likelihood of an event occurring;the extent of harm or benefit involved in any potential outcome.In addition, risk assessment includes a consideration of the imminence of a harmful event. Confusion can arise if risk assessors are not clear about all of those elements and how they interrelate with each other. Any discussion of risk must also recognize that decisions about future likelihood and harm or benefits are not certain; assessors have to live with uncertainty and this is an intrinsic feature of the risk-assessment process.
Purpose
Based on this understanding of the nature of risk – its key components and inherent uncertainty – the basic purpose of risk assessment in individual cases, therefore, should be clearly understood as:
identifying what risks are being considered to whom and why, being specific about the behaviour(s) or event(s) of concern;calculating the likelihood or probability that the behaviour or event in question will occur and considering its imminence, that is, how soon it is likely to happen;estimating the likely impact and consequences of the behaviour or event in question and on whom;identifying the circumstances and conditions that increase or decrease likelihood and/or impact.Before you go on to read the rest of the chapter, you may want to use the following activity to help you consider your own practice and to inform your subsequent reading.
This table could be used in supervision to structure a discussion about a case. It could also be used in teaching and training to structure small group discussions about a case study. If you are currently practising, use this table to have a discussion with a colleague or a supervisor about a current risk assessment.
Practitioners who are unsure about what they are seeking to achieve, and why, are sometimes part of decision-making processes that fail to protect vulnerable children and other victims of violence or neglect (Laming 2003). Being clear why you are gathering, analysing and recording information is essential for making good quality decisions.
Individuals and contexts: different risks and their effects
To achieve this clarity of purpose, practitioners need to be precise and specific as they consider each of the elements listed above. As they are doing so in a range of working contexts, they will also require knowledge about different groups of service users, about specific working contexts and about the context within which the risk may occur. For example, if you are concerned with risks to older people, this may involve risk within their own home, sometimes from members of their own family, or it may involve risks in care homes from members of staff.
So what is under consideration when assessing risk for specific groups of service users? The World Health Organization (2002: 126) quotes this definition of elder abuse: ‘Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.’ Note that abuse may arise through action or inaction.
This initial definition can be expanded in relation to older people by identifying a range of abuse types:
physical abuse – the infliction of pain or injury, physical coercion, or physical or drug-induced restraint;psychological or emotional abuse – the infliction of mental anguish;financial or material abuse – the illegal or improper exploitation or use of funds or resources of the older person;sexual abuse – non-consensual sexual contact of any kind with the older person;neglect – the refusal or failure to fulfil a care giving obligation. This may or may not involve a conscious and intentional attempt to inflict physical or emotional distress on the older person. (WHO 2002: 1270)Equivalent definitions can be given for other areas of practice; for example, the DCSF (2010: 38) offers this definition of abuse and neglect of children: ‘Abuse and neglect are forms of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institutional or community setting, by those known to them or, more rarely, by a stranger, for example, via the internet. They may be abused by an adult or adults, or another child or children.’ Munro (2011) reminds us that vulnerability to abuse will vary across individuals, depending in part on the characteristics of the child; for example, babies and teenagers having different needs and experiences.
For any working context, practitioners need to have knowledge therefore not only of the range of risks they are considering, but also of the potential impact of those risks on victims. A consideration of the emotional abuse of children includes age or developmentally inappropriate expectations being placed on them (DCSF 2010). A child protection worker would need to understand how children develop healthily and safely in order to make judgements about signs of inappropriate expectations and how serious their impact is likely to be. They would, in addition, need to have some understanding of context to support a judgement about the likely impact on a given individual.
While a single event may cause such harm, more usually it is a compilation of events ‘both acute and longstanding, which interrupt, change, or damage the child's physical and psychological development’ (DCSF 2010: 36). They suggest that assessors should consider the nature of the harm and its impact, special needs and parental capacity and the context of the family and wider environment. In working with adults, similar specialist understandings are needed, for example when working with a vulnerable adult with communication difficulties (Pritchard 2008).
It can be difficult for practitioners to be confident in making judgements if there is a lack of clarity or agreement about what is meant by significant harm. For example, practitioners may find it hard to make judgements about the extent of harm arising from long-lasting neglect. Practitioners may worry that they are making value judgements, for example, about standards of child care, but need to have a focus not just on health and safety risks for children, but also on the child's lived experience. For example, if a child is smelly and dirty, how does that affect friendships and normal development? ‘Abuse and neglect rarely present with a clear, unequivocal picture. It is often the totality of information, the overall pattern of the child's story that raised suspicions of possible abuse or neglect’ (Munro 2011: 79). This quote could equally apply to other groups of service users.
All the examples so far have focused on potential harms. Risk assessment is most usually thought about in terms of bad outcomes and the reduction of risk. Risk reduction can, however, sometimes be achieved by supporting strengths and should be combined with attempts to support positive outcomes and to actively engage service users so that they can play a part themselves in risk management. An understanding of individuals in context must include potential strengths and resilience and the place of positive risk taking (Titterton 2005, 2011). For example, taking risks can be important in helping young people and others learn and develop resilience and in allowing for the retention of independence amongst older people or those with dementia (Bornat and Bytheway 2010; Manthorpe and Moriarty 2010; Boeck and Fleming 2011). Both risk reduction and purposeful risk taking should be focused on outcomes and should include the involvement of, and informed decision making by, service users.
Holding the balance
This balancing of risk reduction and positive risk taking is just one of the balances taken into account in risk assessment, including:
weighing risk prevention against the risks posed by intervention, where there may be a lack of clear evidence to support the likely efficacy of different courses of action (Sheppard 2008; Milner and O'Byrne 2009; Davidson-Arad 2010);maximizing the well-being of those concerned, while minimizing harm to individuals, or the harm that an individual may pose to others (Munro 2008a);balancing taking risks in order to allow the development of strengths and opportunities with the avoidance of the risk of harm;balancing intervening in order to reduce risk and improve people's lives with a responsibility to use limited resources wisely;balancing role clarity for the practitioner about risk reduction while also sustaining a collaborative approach and engagement with service users;balancing individual interventions with interventions targeted at damaging social contexts; balancing prevention with protection (Davies 2008; Carey and Foster 2011).For example, in different working contexts, protection of individuals and of the public has to be balanced with the rights of older people to autonomy and freedom of action; protection of children balanced with a family's right to privacy; and a proper concern with the risk of violence amongst the mentally ill balanced with the dangers of stigmatizing and unfair restrictions of liberty (McDonald 2010a, b; Maden 2011).
This activity asks you to think about the potential balance of benefits and harms to all those affected by a risk decision. You could apply this thinking to the following case study.
Helen is a single mother of 23, living with her two children, Sam, 5 and Molly, 3. The children are subject to an interim care order. Helen is separated from the children's father who is a chaotic poly-drug misuser. There is a history of domestic violence in their relationship and of the children witnessing that violence, although no suggestion of physical injury to the children. Helen herself has a long-standing history of drug misuse and is currently engaging with a treatment agency and is receiving a script as she recovers from a heroin addiction.
The children were initially allowed to stay with Helen, despite some concerns, because she usually provides them with love and stimulation and meets their physical needs well. The two children are close to each other and clearly attached to their mother. Sam is a quiet boy who wants to please adults around him and who worries about his mum. Molly seems more relaxed and less aware of the difficulties in the family. There have been concerns in the past about Helen neither paying attention to the children, nor cooperating with Sam's school and about there being insufficient money to meet the children's basic needs. There were concerns for their safety and for the abuse they witnessed when their father was in the home. When she is feeling stressed, Helen finds the children add to her feelings of pressure and in the past she has used drugs to cope with those feelings.
The original decision for the children to remain with their mother has been reassessed as there is evidence that Helen, while taking her script, has also used heroin over the last few weeks. She had also resumed contact with their father, although she says that he has not returned to live with them or had any contact with the children. She wasn't honest with staff about these developments. The children's school and nursery had raised concerns that they were arriving late and Helen was sometimes very late in collecting them. They still appeared well cared for but Sam was even quieter than usual and reluctant to part from his mother.
